Provider Demographics
NPI:1144460668
Name:NELSON-WADE, ALISA M
Entity type:Individual
Prefix:DR
First Name:ALISA
Middle Name:M
Last Name:NELSON-WADE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2219 LOGANVILLE HWY
Mailing Address - Street 2:HWY 20
Mailing Address - City:GRAYSON
Mailing Address - State:GA
Mailing Address - Zip Code:30017-1622
Mailing Address - Country:US
Mailing Address - Phone:678-377-1800
Mailing Address - Fax:678-377-0740
Practice Address - Street 1:2219 LOGANVILLE HWY
Practice Address - Street 2:HWY 20
Practice Address - City:GRAYSON
Practice Address - State:GA
Practice Address - Zip Code:30017
Practice Address - Country:US
Practice Address - Phone:678-377-1800
Practice Address - Fax:678-377-0740
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-24
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA123361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice